Evolving Technique Update: Alternative to 2 Stage Revision, When I - - PowerPoint PPT Presentation

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Evolving Technique Update: Alternative to 2 Stage Revision, When I - - PowerPoint PPT Presentation

Jan 26, 2023 837 likes •1.06k views

Evolving Technique Update: Alternative to 2 Stage Revision, When I Can, When I Cant, and What I Do Michael B. Cross, MD Assistant Attending Orthopaedic Surgeon Disclosures Consultant: Smith & Nephew Link Orthopaedics

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Evolving Technique Update: Alternative to 2 Stage Revision, When I Can, When I Can’t, and What I Do

Michael B. Cross, MD Assistant Attending Orthopaedic Surgeon

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Disclosures

  • Consultant:

– Smith & Nephew – Link Orthopaedics – Exactech Inc. – Intellijoint – Acelity – Theravance Biopharma – Zimmer Biomet

  • Honorarium

– Acelity

  • Editorial Board

– Techniques in Orthopaedics – Bone and Joint Journal 360 – Journal of Orthopaedics and Traumatology

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SLIDE 3

What are my options?

  • Treatment Options

 Suppression

– Susceptible organism – Stable implant

 I&D, Liner Exchange, & Component retention  2-stage protocol  1-stage protocol  Girdlestone/Amputation

– Recalcitrant / resistant organisms – Multiply re-infected patient – Medically infirmed

3 Alternatives to the 2-Stage Exchange

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Antibiotic Suppression

Alternatives to the 2-Stage Exchange 4

  • Indications:

 Acute hematogenous infection  High operative risk  Immunocompromised

  • Contraindications:

 Resistant organisms  Late onset PJI  Chronic PJI

Never my choice of treatment

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Relative Success - Antibiotic Suppression

21 patients, median age of 67 years (range 21 - 88), and median follow-up of 21 months (range 3 - 81)

Coagulase negative staphylococci (CNS) (n=6), S. aureus (n=6) and polymicrobial flora (n=4) most common

Most patients with CNS and S. aureus were treated with minocycline (67%) and clindamycin (83%)

Overall, treatment was successful in 67% of patients – Failure was due to persistent joint pain (n=1), surgical intervention because of an uncontrolled infection (n=3), and death due the infection (n=3)

Alternatives to the 2-Stage Exchange 5

34 patients (24 hips, 10 knees); 12 early, 16 delayed and six late infections

MSSA (4), MRSA (8), MSSE (4), MRSE (5), Enterococcus faecalis (2), MRSE + E. faecalis (1 mixed infection), and MRSA + Pseudomonas aeruginosa (1 mixed infection)

All patients began antimicrobial therapy within 3 months of the clinical onset of infection

Infection was suppressed in 31 (91.2%) of 34 patients, with no relapse being observed in 17 (50%) patients after follow-up for 9–57 months following discontinuation of antibiotics

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I&D, Liner Exchange, Component Retention

  • Indications:

 Acute infection (within 2-4 weeks of surgery/symptoms)  Stable implant  Low virulence organisms identified  Soft tissue intact

  • Contraindications:

 Loose prosthesis  Poor soft tissue coverage  Bone/cement mantle compromise  Sinus tract  MRSA or MSSA  Two or more previous I&Ds  >4 weeks of symptoms

Alternatives to the 2-Stage Exchange 6

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Relative Success - I&D, Liner Exchange, Implant Retention

32 patients, mean age of 66 ± 16 years (23 hips, 16 knees) all with S. aureus PJIs

Surgical management of irrigation & debridement, antibiotics and implant retention (DAIR) – all treated with rifampicin-containing combinations for curative antibiotic therapy

Overall, treatment was successful in 75% of patients (25 of 32) – All of the failure cases (relapse or superinfection) were diagnosed while patients were receiving suppressive antibiotics

99 PJIS in 91 patients, median age of 74 years (23-95), 47 hips & 52 knees

Surgical management of irrigation & debridement, antibiotics and implant retention (DAIR)

Median duration of IV antimicrobial therapy = 28 days, followed by chronic oral antimicrobial suppression

The 2-year survival rate free of treatment failure for the entire cohort was 60% (95% CI, 50%– 71%)

Presence of a sinus tract and a duration of symptoms > 8 days were risk factors for failure

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1-Stage Protocol for Infected TJA

  • Implant Removal

 All cement and cement restrictors

  • Aggressive debridement

 Capsule, scar, prior incision, infected bone  Pack the canal after you are done to minimize contamination during

the remaining portion of the debridement

  • Closure
  • Re-Prep and Drape

 New drapes, new sterile instruments, re-scrub, new suction, bovie,

lavage

  • Revision THA
  • Re-implantation
  • Closure

6

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My Indications for One Stage Revision in 2017

  • Acute Infections (<3-6 weeks from surgery)
  • THA with noncemented components without ingrowth/ongrowth
  • No data on this
  • Chronic Infections
  • Known organisms with known antibiotic sensitivity
  • Prefer lower virulent organism
  • Prefer elderly or lower demand patient but not necessary
  • Intact soft tissue envelope
  • No sinus tract that is outside the wound

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Contraindications – One stage (Indications for Two-Stage)

  • Failure of ≥ 1 previous 1-staged procedures or

I&D liner exchange

  • Infection spreading to the neurovascular bundle
  • Organism unknown or no sensitivity data known
  • Non-availability of appropriate antibiotics
  • High antibiotic resistance
  • Sinus outside the incision
  • Poor soft tissue envelope (i.e. needs additional

surgery to get coverage of the wound)

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Relative Success – 1 Stage Exchange

  • 24 one-stage revision surgeries were performed for septic failure of a total hip

arthroplasty in 24 patients without draining sinuses, without immunocompromise, and with adequate bone quality after debridement

  • Twelve patients died and none were lost to follow-up at a minimum of 10 years after the

procedure

  • Standard approach of meticulous debridement, use of antibiotic-impregnated

cement, and use of 3 to 6 months postoperative oral antibiotic therapy

  • Infection reoccurred around two hips (8.3%)

Alternatives to the 2-Stage Exchange 11

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Relative Success – 1 Stage Exchange

  • N=63 one-stage revisions (6 UKAs, 37 primary TKAs, and 20 hinged knee

endoprostheses)

  • Excluded MRSA, MRSE, and culture-negative PJIs
  • Mean 36 month follow-up (minimum 24 months)
  • Results:

 One-stage revision of septic knee prostheses achieved an infection control rate

  • f 95%

 3 of the 20 hinged endoprostheses failed (infection recurrence)

– All 3 had chronic PJIs >5 years in total length and had previously undergone multiple revisions

Title of Presentation Here 12

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Alternatives to the 2-Stage Exchange 13

Author Follow-up (months) N

  • No. of eradicated

infections Eradication rate (%) Buechel et al. [6] 22 22 20 90.9 Goksan and Freeman [17] 60 18 16 88.9 Lu et al. [38] 20 8 8 100 Silva et al. [55] 48 37 33 89.2 Sofer et al. [56] 18 15 14 93.3 von Foerster et al. [63] 76 104 76 73.1 Total 204 167 Mean 40.7 89.2 SD 24.4 8.9 Mean eradication rate 81.9

Table 1. Infection eradication rates after one-stage direct exchange for knee periprosthetic sepsis (Romano et al, Knee Surg Sports Traumatol Arthrosc, 2012)

Relative Success – 1 Stage Exchange

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Girdlestone/Amputation

  • Indications:

 Recalcitrant / resistant organisms  Multiply re-infected patient  Medically infirmed  Non-ambulatory patients  Patients with limited bone stock  Poor soft tissue coverage  Infections due to highly resistant organisms for which there is limited

medical therapy

 Previous failed two-stage revisions

Alternatives to the 2-Stage Exchange 14

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What’s my best option?

Treatment Option Relative Success Rate (Infection Clearance) Published Risks for Failure Antibiotic Suppression ~30-67% Virulent organisms, late onset DAIR ~50-86% Presence of sinus tract, late onset, younger age, virulent organisms, history of RA, ESR > 60 mm/h, and coagulase-negative staphylococcus, MRSA 1-Stage ~73.1-100% Culture negative, Polymicrobial, gram negative, and methicillin-resistant

  • rganisms

Amputation ~74%

Alternatives to the 2-Stage Exchange 15

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I & D or Removal?

Alternatives to the 2-Stage Exchange 16

See Next Figure

Osman et al, Clin Inf Disease, 2013

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1-Stage or 2-Staged?

Alternatives to the 2-Stage Exchange 17

See Next Figure

Osman et al, Clin Inf Disease, 2013

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Resection or Amputation?

Alternatives to the 2-Stage Exchange 18

Osman et al, Clin Inf Disease, 2013

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Conclusions

  • Suppressive antibiotic therapy in the treatment of chronic prosthesis

infections has limited clinical benefit and is associated with a substantial risk of adverse effects

  • In the presence of an acute PJI with an identified organism I & D

+ liner exchange vs 1 stage revision

 Depends on whether components well fixed

  • In the presence of a chronic PJI with an identified organism, no sinus

tract, and good soft tissue coverage 1-Stage Revision

  • Multiple failed two stages, highly resistant organisms, nonambulatory

Girdlestone vs Amputation

Alternatives to the 2-Stage Exchange 19